Briana Contreras

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 What are some of the most common HCP [health care provider] barriers related to getting access for their patients, especially for novel targeted approaches, such as dual HER2-targeted regimens?

Among the commercially insured patients, prior authorization barriers are present. That limitation usually is a delay from appropriate therapy, but it can be a detour. Actually, even getting appropriate imaging can be a challenge. In patients with metastatic breast cancer, we do need appropriate imaging prior to the initiation of treatment, [so] managing the prior authorization and scheduling can be a barrier that frequently delays treatment. That’s a challenge. Among Medicare beneficiaries, it’s much more straightforward. The Medicaid program has some novel challenges around formulary choice, around reimbursement and single dose vials, which remains a challenge to patients getting the appropriate therapy that they need. Among the uninsured patient population, there’s a whole hurdle of new challenges to try to get patients the care that they need. I would say that that’s very region specific. I come to you from Texas where we have [a population of] 30 million, and a high percentage of the population is uninsured. It’s about 17% of the general population, but 25% of the population between 18 and 64. So that poses a challenge. Many manufacturers can be generous with indigent patients by donating drugs. Many of our cancer centers have indigent programs that allow patients to receive care. But this is a problem that’s highly variable based on the region of the state and region of the country. So, I talk about the challenges that we have in Texas, but I practice in West Austin, which is very different from the Rio Grande Valley. And so, I would say that more broadly as you think about this conversation in a national audience, is that those are regional specific concerns that can be highly variable.

 Can you share some of the access challenges patients have faced getting targeted treatments for metastatic breast cancer? Could it be related to cost, physical access, or coverage?

Where I practice in Texas, the major challenge is patients not having access to insurance products, so there’s a high burden of uninsured patients. My own organization has employed social workers to get patients enrolled in the breast cancer Medicaid program—we call it “pink Medicaid”—there are different criteria for breast and cervical cancer than there are for traditional Medicaid for adults. So, we’ve been more successful at getting patients on the “pink Medicaid” program. But it takes some time. Eligibility has to be verified frequently with more aggressive cancers like HER2-positive cancers, but you want to start patients on treatment right away. That can be a challenge. So, navigating the issue of insurance is a challenge. Understanding when you can get drugs donated is a challenge. Then even for Medicare beneficiaries, when some of these involve oral oncolytics, like tucatinib or capecitabine, you have to manage their Part D benefits. Some Medicare beneficiaries have Part D benefits because they’re participants in the Part D program. Some have commercial counterparts. Some do not. So, managing their therapies to manage their out-of-pocket costs becomes a real consideration. In some patients that don’t have a Part D plan, it can be cost prohibitive for them to have a strategy of oral oncolytics because it’s not covered under the traditional program.

 How does the use of HER2-targeted therapies impact site of care considerations?

Well, I would say that I don’t think that patients make a choice about site of care based on HER2-targeted therapies. But when patients receive outpatient infusion in a hospital setting, particularly a 340B hospital setting, the hospitals are able to purchase those drugs at a substantial discount. So somewhere between a 25% and 50% discount on trastuzumab, pertuzumab, and other oral and IV [intravenous] therapeutic interventions, in contrast to say a community oncology or private practice clinic, that does not purchase them at a discount.

 Now did your use of HER2-targeted therapies for patients with metastatic breast cancer change during the COVID-19 pandemic? And if so, how do you think these changes will continue now that COVID-19 vaccines are available?

 It’s a great question. I will say that has been very regional. If you look broadly across the Medicare population, we did a study with Community Oncology Alliance and Avalere Health that we published in [JCO] 

 this last year and we understand that there was a great impact in cancer care from the COVID-19 pandemic. We saw decreases in cancer screening, biopsies, new cancer diagnoses, and subsequent therapeutic interventions. So, we know that it was pervasive; in April and May of 2020 it was down by 80% in comparison to 2019. I would say more broadly over the year, it’s probably about 30%. It’s difficult because we know of course that those cancers are happening, they’re just being diagnosed later. So yes, cancer care was absolutely impacted. I think it’s highly variable though. Because in places like West Austin, where I practice, our radiology centers stopped screening during that time, whereas our practices in West Texas sort of operated business as usual. I’m sure that if you lived in Queens, New York, which was greatly impacted by the pandemic, if you were receiving your care at the hospital setting, you probably didn’t go in for it whenever they had high rates of COVID-19. So, I think those are very regional stories. But if you look at global population health impact, generally speaking, there were substantial reductions in cancer care delivery and cancer care diagnoses during the pandemic. I anticipate that those will return to more normal rates after the pandemic, as people are vaccinated, and our rates appear to be improving. But I suspect that with regards to screening and new cancer diagnosis and delayed cancer diagnosis, that those will be changes that we will continue to appreciate for the next years to come. I think it’s true for all of us. And I think each one of us has our list of things that have had deferred maintenance during the pandemic, whether it’s our haircuts or dentist visits or screening mammograms, and we just simply can’t address them all at once. Some of them will take priority. If you lost your job during the pandemic, that’s probably the priority that’s going to demand your time for several months before you ever get to the hairstylist or the dentist or the imaging center to get your breast cancer screening, and that is a shame. So, I think that if we can have efforts to heighten awareness about the importance of screening, we have better opportunities to reduce morbidity and mortality of cancers, because we’re able to catch them early. In the words of Ben Franklin, “An ounce of prevention is a pound of cure.” That’s certainly true of cancer. We want to see people screened, and screened early, but I suspect that we’re going to see the ramifications of those delays for many years to come.

Videos

A key opinion leader describes treatment access considerations among patient with HER2-positive metastatic breast cancer.

Challenges of Patient Access to HER2+ mBC Therapies

Below is a brief Q&A of the interview with Gottesman, which has been edited for clarity.

 Most of our readers and listeners are familiar with a stop loss insurance. So first, could you explain the difference between medical reinsurance and stop loss? And then secondly, is reinsurance completely different from stop loss? Or is it a broader category that includes stop loss?

 Essentially, they are similar in concept. So what you're doing is protecting an underlying risk taker from catastrophic financial exposure to a particular claim. So, whoever the risk taker is, in the case of employer stop loss, ESL, which we're most familiar with, it's almost always an employer group who's self insuring their health plan. So it's just for one employer group. It really goes back to how comfortable they are with their balance sheet, what type of Stop Loss Coverage they're willing to access at what deductible level; so it's almost always specific to just a single employer. That employer group is being administered by a third party claim payer of some sort. It could be it could be a number of entities that are administering the claim. So in the case of medical reinsurance, it's broadly based into three different categories. Broadly, based in sense that an HMO is one risk-taking entity we would reinsure. 

The second broad category is a physician group or provider group. Also, that segment is typically referred to as provider access. Thirdly, there's a category called medical access. Medical access is simply an underlying risk insurance company of some sort that's limiting, or wants to limit their own exposure to something they wouldn't have written. It could be, for example, a stop loss carrier, or someone like a stop loss carrier putting risk into captive. And then they're asking us to reinsure that captive at a certain level. So those are the three broad base categories of HMO provider and medical access. 

 What are the key determinants for the coverage need for medical reinsurance?

: Key determinants are almost always "What's the financial risk tolerance for the underlying entity?" "What can they tolerate based on the size of their balance sheet and what does their CFO think is adequate coverage for the risk they're assuming?" So it's interesting to see the differences and HMO, for example, can manage their own risks quite well, because they're actually performing the services themselves when they're in network and within their own facilities. 

So you may see an HMO saying, "Hey, we can take coverage on our entire patient population, when it's in network, or within our system have a certain high retention or high deductible." And if it does leak out to a specialty facility of some kind, then we'd be less comfortable with that and we'd structure our risk accordingly. Same is true for provider groups. Providers sometimes take risk on a very specific basis from these managed care organizations that they are receiving patients from. So they may want to, and in a lot of cases, these are things people don't see. But there's something called a doper, which is simply a deal for delegation of financial responsibility.

The construct of a of a provider risk contract can get quite detailed. It may be just on inpatient services, it might be on a specific type of care. It might be for a specific patient class, it could be Medicare, it could be Medicaid, or it generally could be on a commercial population, which in those categories, commercial population patients are much more subjected to large dollar swings because there is the underlying Medicare fee schedule. 

Podcasts

In this special episode of Tuning In to the C-Suite podcast, MHE Associate Editor Briana Contreras met with HM Insurance Group Sales Director Adam Gottesman to discuss the ongoing and critical need for reinsurance in healthcare.


The Importance of Reinsurance, Per Adam Gottesman of HM Insurance Group

Climbing the Career Ladder: Ninth* of 10 profiles of healthcare executives and their careers.

Gurpreet “Sunny” Singh’s career has been a series of stepping stones – always improving from one entrepreneurial start-up to the next, eventually leading to the successful founding of the now leading global health IT company, Edifecs. Throughout his business ventures and education at the Indian Institute of Technology in his native country of India, Singh approached every opportunity to learn as a new attempt at innovation. With a knack for learning and creativity, Singh took his entrepreneurial spirit to the United States with only $200 in his pocket to attend Montana State University on a full-ride scholarship for industrial engineering.

It was during his time as a student at Montana State where his work ethic and unrelenting drive to succeed took root. Singh accepted as many jobs as he could to send money back home – from tutoring student-athletes, to packing and moving hay bales, and even fishing in Alaska during the summer. When it was time to begin his career in technology and innovation, he joined Expeditors International and then Microsoft, where he started narrowing in on a goal: to make electronic data more accessible, shareable, and optimized, and as a result more powerful.

 in 1996 out of the garage of his home outside of Seattle. The company provides integrated solutions for data exchange, analysis, and insights. Today, it has more than 350 healthcare customers, serving more than 215 million people.

Not all 25 years of Edifecs’ role in healthcare have been smooth sailing The company lost a big deal, IRS notices began coming in, and it had to suspend salaries. The stress of this period was all-consuming, Singh says, but it also drove him turn things around and put Edifecs back on a path to success.

“I figured out how to hustle, to stretch a dollar, to find innovative solutions, to work hard and not accept no for an answer,” Singh sayss. “While these early trials were difficult, they ultimately strengthened the company and led us on a path of tremendous growth and resilience and a valuation of over $1.5 billion in 2020.”

Singh recently transitioned from being CEO to chairing the company’s board. He continues to serve the organization by ensuring Edifecs is on the path to produce leading health IT solutions.

When he’s not serving as chairman, Singh also leads innovative well-being initiatives for the state of Punjab by way of his next entrepreneurial venture, 

Singh said his previous experiences from early childhood in both India and Ghana, through school, and into the first years of his career shaped the leader that he is today. He noted there are a few principles that have been consistent throughout his career. First, would be the people.

“My early experiences gave me an appreciation for what it takes to make a company run successfully,” he says. “Edifecs would not be the outstanding company it is today without our world-class team of associates. They’ve helped build this company and continuously contribute to our growth and success.” 

Second, is the importance and value of workplace wellness: “In order for your team to perform well, you need to ensure they are healthy and happy.”

“Third, you can do “good” while doing “well.” “While I’ve had the opportunity to build Edifecs into a global health IT player, our team has also been focused on giving back to our community and being strong stewards of the planet,” Singh says. “We believe wellness extends beyond the healthcare industry to the planet we all share. Since founding the company, we’ve embraced a green approach to our operations and made conservation a pillar of our culture.”
For those who may sit on full commitment toward their passions or growing their entrepreneurial ventures, Singh recommends following the advice his father passed down to himself.

“My father always encouraged me to pursue my passions and to dream big,” he said. “He also raised me to be generous and compassionate – to honor the human spirit. This is something that I’ve carried with me for my entire life, and it’s shaped the work that I do.”

He said this philosophy stretches from his time at Montana State in the 1980s, directly to his work today in India to improve the lives of billions through innovative wellbeing initiatives with RoundGlass.

*Eight of these profiles were published in our print issue. Two more were published only online.

Articles

Gurpreet “Sunny” Singh, chairman of the board at Edifecs, said he follows a philosophy in life that stretches from his time at Montana State University in the 1980s, directly to his work today, at Edifecs, and in India to improve the lives of billions through innovative wellbeing initiatives with RoundGlass. “My father always encouraged me to pursue my passions and to dream big. He also raised me to be generous and compassionate – to honor the human spirit. This is something that I’ve carried with me for my entire life, and it’s shaped the work that I do.”

Gurpreet “Sunny” Singh, Edifecs: Difficult Roads Lead to Wonderful Destinations

In this week’s episode of Tuning In to the C-Suite podcast, MHE had the pleasure of speaking with Sach Jain, CEO of Carrum Health. In the discussion Jain touched on how adopting value-based care is treating conditions and lowering cost burdens, but there remains to be concern in medical spend when it comes to planned surgeries. Jain also talked about how adopting bundled payments can be just as good of a solution as the newer price transparency rule when assisting in patient’s high medical costs. 

Value-Based Care, New Price Transparency Rule is Assisting Cost Burdens and More, But Focus Should be on Bundled Payments Too, Per Sach Jain of Carrum Health